1
Q
Make sure to go back to cosmetics
A
2
Q
Know GCS, and that we use best response, left vs right .
A
3
Q
Know classes of hemorrhagic shock
A
4
Q
Head Injury classification GCS
A
Severe Head Injury/Coma – GCS score of 8 or
*
*
*
less.
Moderate Head Injury – GCS score of 9–12.
Mild Head Injury – GCS score of 13–15.
Denotation of T after the score is applied to an
intubated patient.
5
Q
Zones of the neck
A
Zone 1 – thoracic inlet to cricoid cartilage.
*
Zone 2 – cricoid cartilage to angle of the
mandible.
*
Zone 3 – angle of the mandible to the base of
the skull.
6
Q
What is the ideal line of osteosysnthesis of the mandible
A
A line around the mandible where plating the
tension and compression forces are balanced,
7
Q
Pros and cons of locking plates and screws, non locking too
A
Locking plates/screws:
– Screws lock into the plate while it is being
–
tightened.
– Does not require a perfect adaptation of the
–
plate to the bone.
– The plate bears the load of mechanical
–
forces.
8
Q
Plates named after the out dimeter of the screw.
A
9
Q
What is primary bone healing
A
No fracture callus forms.
–
– Heals by a process of:
–
(a) Haversian remodeling directly across
the fracture site if no gap exists (con-
tact healing)
(b) Deposition of lamellar bBony callus forms across fracture site to
–
aid in stability and immobilization.
– Occurs when there is mobility around the
–
fracture site.
– Secondary bone healing involves the for-
–
mation of a subperiosteal hematoma, gran-
ulation tissue, and then a thin layer of bone
forms by membranous ossification. Hyaline
cartilage is deposited, replaced by woven
bone and remodels into mature lamellar
bone.
10
Q
What is the process of secondary bone healing.
A
Bony callus forms across fracture site to
–
aid in stability and immobilization.
– Occurs when there is mobility around the
–
fracture site.
– Secondary bone healing involves the for-
–
mation of a subperiosteal hematoma, gran-
ulation tissue, and then a thin layer of bone
forms by membranous ossification. Hyaline
cartilage is deposited, replaced by woven
bone and remodels into mature lamellar
bone.
11
Q
What is in a physical exam
A
After confirming the patient is stable and the
airway secure, begin the head and neck
trauma exam. This should be systematic and
concise.
Evaluate general demeanor and responsive-
ness. Patient cooperation may be extremely
difficult with pediatric or inebriated patients.
Evaluate neurological status to determine the
level of consciousness (Glasgow scale).
Evaluate for facial asymmetry, lacerations
(rule out Stenson duct or facial nerve injury),
edema and ecchymosis.
Examine the cranial nerves II–XII and note
any paresthesia (V1, V2, V3), or facial nerve
deficits.
If the orbit is involved, evaluate extra ocular
movements, pupillary reaction, direct and
consensual visual reflexes, monocular (indica-
tive of retinal detachment) or binocular diplo-
pia (can be secondary to edema or entrapment
and restriction of gaze), Tonometry should be
used for evaluating intraocular pressure. A
fundoscopic exam is indicated for for evaluat-
ing the retina and optic nerve, and hyphema.
A slit lamp exam is useful in evaluating the
*
*
*
*
eyelids, lacrimal system, cornea and to rule
out the presence of foreign bodies. Exam
should assess for the presence of proptosis,
dystopia (disturbance in globe position in the
vertical and horizontal planes) or enophthal-
mos. Look for periorbital ecchymosis (Racoon
eyes). Evaluate for telecanthus. Consider oph-
thalmology exam/clearance.
Evaluate the ears for the presence of ecchy-
mosis behind the ears (Battle’s sign) or otor-
rhea, which may be indicative of a base of
skull fracture (if positive neurosurgical con-
sultation is required). Rinne and Weber exam
to screen for hearing. Otoscopic exam to eval-
uate tympanic membrane and EAC (if injury
apparent ENT should be consulted).
Evaluate for exit wounds if a projectile was
involved.
Evaluate the midface for loss of projection,
edema, ecchymosis, and step deformities.
Evaluate the nose for asymmetries, blood, rhi-
norrhea, and septal hematoma.
Evaluate jaws for range deviations on opening
(this may indicate a condylar or subcondylar
fracture), arch step deformities, lingual ecchy-
mosis (highly indicative of a mandible frac-
ture), hematomas, and intraoral lacerations.
Evaluate the state of the dentition (dental frac-
tures, missing teeth, changes in occlusion).
For a pediatric patient correlate dental devel-
opment with chronological age.
Evaluate for a chin laceration, preauricular
edema, or ecchymosis as these can be sugges-
tive of a condylar fracture.
The floor of mouth swelling or the possibility
of airway compromise should be noted.
12
Q
What radiographs for those with missing teeth.
A
abdominal X-ray
(KUB) and chest X-ray must be performed.
13
Q
What fracture gives you anterior open binte? unilateral open bite? posterior crossbiet? prognathic bite? Retrognathic bite?
A
Anterior open bite – bilateral condylar or
–
angle fractures.
– Unilateral open bite – ipsilateral angle,
–
condylar and parasymphyseal fractures.
– Posterior crossbite – symphyseal and con-
–
dylar fractures with splaying of the poste-
rior segments.
– Prognathic bite – TMJ effusions.
–
– Retrognathic bite – condylar or angle
–
fractures
14
Q
contraindications for closed reduction
A
Medical conditions that should avoid inter-
–
maxillary fixation.
– Alcoholics.
–
– Seizure disorders.
–
– Mental retardation.
–
– Nutritional concerns.
–
– Respiratory diseases (COPD).
–
– Unfavorable fractures.
–
15
Q
Techniques for Closed Reduction:
A
Erich arch bars.
*
Ivy loops.
*
Essig Wire.
*
Intermaxillary fixation screws.
*
Splints.
*
Bridal wires.
16
Q
Indications and contraindications for Open Reduction
A
Unfavorable/unstable mandibular
–
fractures.
– Patients with multiple facial fractures that
–
require a stable mandible for basing
reconstruction.
– Fractures of an edentulous mandible frac-
–
ture with severe displacement.
– Edentulous maxillary arch with opposing
–
mandible fracture
If a simpler method of repair is available,
maybe better to proceed with those options.
*
Severely comminuted fractures.
*
Patients with healing problems (radiation,
chronic steroid use, transplant patients).
*
Mandible fractures that are grossly infected.
17
Q
Biomechanical difference of the edentulous mandible and biological differences
A
Decreased bone height leads to a decreased
–
buttressing effect (alters plate selection).
Significant bony resorption in the body
–
region.
– Significant effect of muscular pull, espe-
–
cially the digastric muscles.
– Incidence of fractures highest in the body.
–
– Atrophy creates saddle defects in the
–
body.
Biological differences:
– Decreased inferior alveolar artery (centrif-
–
ugal) blood flow.
– Dependent on periosteal (centripetal) blood
–
flow.
– Medical conditions that delay healing.
–
– Decreased ability to heal with age.
–
18
Q
How to do closed reduction of the edentulous patient, how about open reduction
A
Closed Reduction.
– Use of circummandibular wires fixated to
–
the piriform rims and circumzygomatic
wires with patient’s denture or Gunning
style splints.
19
Q
Wassmund scheme of condylar process fractures
A
I – minimal displacement of the head
–
(10–45°). II – fracture with tearing of medial joint
–
capsule (45–90°), bone still contacting.
– III – bone fragments not contacting, condy-
–
lar head outside of capsule medially and
anteriorly displaced.
– IV – head is anterior to the articular
–
eminence.
– V – vertical or oblique fractures through
–
the condylar head.
20
Q
OPen Reduction of condylar fractions, Zides absolute indications.
A
(1) Middle cranial fossa involvement with
disability.
(2) Inability to achieve occlusion with
closed reduction.
(3) Invasion of joint space by a foreign
body.
(4) Lateral capsule violation and
displacement.
ide’s Relative Indications:
–
(1) Bilateral condylar fractures where the
vertical facial height needs to be restored.
(2) Associated injuries that dictate early or
immediate function.
(3) Medical conditions that indicate open
procedures.
(4) Delayed treatment with misalignment
of segments.
21
Q
What are the indications for removal of teeth in the line of fracture.
A
*
*
Gross mobility.
Periapical pathology.
Preventing reduction.
Roots with a fracture.*
*
Exposed root.
Delay in repair from time of fracture.
Recurrent infection at the fracture site despite
antibiotic therapy.
22
Q
What is Non union
A
Arrested healing after the appro-
priate time has passed (mobility after 4 weeks
without treatment and 8 weeks with surgical
management). Can be multifactorial but includes
mobility at the fracture site, poor reduction,
infection, substance abuse, delay in treatment, or
tooth in line of fracture.
23
Q
what is osteomyelitis and how to diagnose it.
A
Osteomyelitis – Complaint of continued pain,
paresthesia, feeling of the mobility of plate.
Diagnosis can be made with labeled white blood
cell scans (indium-111), bone scans (technetium
99), MRI, or biopsy of bone.
Treatment can
involve removal of hardware with closed
reduction, resection/debridement/cortication of
bone, placement of rigid fixation, IV antibiotics,
and consideration of hyperbaric oxygen therapy.
24
Q
Describe the 3 left fractures
A
LeFort I (Horizontal Fracture) – extends above
the apices of the maxillary dentition across the
nasal septum and maxillary sinuses. Posteriorly itextends through the pyramidal process of the
palatine bone and the pterygoid processes of the
sphenoid bone. It also may involve the fracture of
the palate.
LeFort II (Pyramidal Fracture) – extends from
the nasofrontal region down through the medial
orbital wall, crossing the inferior orbital rim and
zygomatic buttresses. Posteriorly similar to a
LeFort I fracture.
LeFort III (Complete Craniofacial
Disjunction) – fracture lines extend through the
nasofrontal junctions, zygomaticofrontal articu-
lations, zygomaticomaxillary suture, temporozy-
gomatic suture, pterygomaxillary junction,
medial and lateral orbital walls, and superior
articulation of the nasal septum.
25
what are battle signs indicative of
cchymosis in the mastoid
region, suggestive of a base of skull fracture.
26
What's treated last in LEfort 2
Reduce fractures and plate stabilization at the
piriform rim, zygomaticomaxillary buttresses,
orbital rim, and management of NOE compo-
nent if necessary.
*
The orbital floor should be treated last after
ensuring that the zygoma and the maxilla are
in the proper position to prevent increased
orbital volume.
27
Approaches and order of the Lefort 3
Access is usually via a combination of the
transoral, lower lid, coronal approaches.
*
Good mobilization.
*
Place into IMF.
*
Reduce fractures ensuring restoration of ade-
quate facial height and width.
*
Fixate starting at the frontozygomatic suture,
nasal region, zygomaticomaxillary but-
tresses, piriform rims, and zygomatic arch as
*
*
*
needed.
Check occlusion.
Reduce/reconstruct orbit.
Nasal reduction as needed.
28
Receite the maxillary vestibular approach
ncision is placed ~3–5 mm superior to the
mucogingival junction making sure to leave
adequate unattached gingiva for closure.
(Usually extends posteriorly to first molar.)
*
Incise through mucosa, submucosa, and peri-
osteum down to the bone using electrocautery
Bovie or #15 blade.
*
Subperiosteal dissection superiorly and anteri-
orly to piriform buttress and posterior to zygo-
maticomaxillary buttress.
*
May encounter infraorbital canal and neuro-
vascular bundle if dissection extends enough
superiorly.
*
If necessary, may need to dissect nasal mucosa
from the lateral wall, floor, or septum using a
Freer elevator.
29
What to do if malocclusion is noted 1 week post operatively .
Occlusion may spring open after the IMF is
released. Remove fixation and then place
patient back in IMF and make sure occlusion
is stable and condyles are in the fossa before
fixating fractures again; remove from IMF and
recheck occlusion.
Malocclusion Noted 1 Week Postoperatively –
Most likely loss of fixation. Obtain new imag-
ing to confirm and if fixation failed then return
to OR to correct. If malocclusion is minor and
fixation appears intact on imaging, then allow
full healing of fractures and refer for orth-
odontic correction of the minor malocclusion.
30
Where is bleeding from during the mobilization of the maxilla. What is is late bleeding f rom? what is sentinel bleeding
If from the pterygoid muscles at posterior
maxilla, then treat with surgicel or fibrin seal-
ants. If from the pterygoid plexus, then treat
with local anesthesia and packing. If from the
terminal branches of the maxillary artery
(descending palatine, PSA, or sphenopalatine
arteries) treat with vessel clips and/or anterior
and posterior nasal packs. If local hemostatic
measures are used and bleeding is still not
controlled, then consider embolization with
interventional radiology. Late bleeding may
occur due to pseudoaneurysm formation
31
ZMC fractures, what are the zygomatic articulations and the is the weakest point of the ZMA
(frontozy-
gomatic, zygomaticomaxillary, zygomatico-
sphenoid, and zygomaticotemporal). These
sutures represent common areas of fracture
points.
It should be noted that the weakest portion of
the zygomatic arch is not the
zygomaticotemporal suture, but a point
approximately 1.5 cm posterior to this suture.
32
Name the knight and north based on waters view? what about Zingg's classification based on CTs
Group 4 – medially rotated.
–
– Group 5 – lateral rotation outward.
–
– Group 6 – complex fractures.
xZingg Classification based on review of CT
scans.
– Type A fractures are incomplete zygomati-
–
comaxillary complex and broken into three
subcategories:
A1 – Isolated arch fracture.
A2 – Isolated lateral wall.
A3 – Isolated inferior orbital rim.
– Type B – monofragment with all four
–
buttresses.
– Type C – comminution of zygomatic bone
33
What does deepening of the supratasal crease indicate
Deepening of
the supratarsal crease is one of the earliest
signs of enophthalmos.
34
what's in a good orbital fracture exam. Describe the physical exam of a ZMC
mperative including visual
acuity, assessment of extraocular muscles in
the six cardinal fields of gaze, integrity of rim,
ecchymosis, hyphema, shape of pupil (trau-
matic mydriasis or iridodialysis), reactivity of
pupil, size of pupil, subconjunctival ecchymo-
sis, periorbital edema/ecchymosis, and che-
mosis and position of the globe.
Flattening of the malar eminence. Decreased
projection is best assessed from a bird’s eye
view.
Depression in the preauricular region denot-
ing flattening of the zygomatic arch.
Antimongoloid slanting (due to disruption of
the frontozygomatic suture and inferior dis-
placement of Whitnall’s tubercle).
Neurological disturbances over the distribu-
tion of the infraorbital nerve.
Step deformities denoting discontinuity of the
orbital rim, zygomaticomaxillary buttress, and
frontozygomatic region.
Ecchymosis in the maxillary vestibule
(Guerin’s sign).
35
What does antimongoloid slanting incite
Antimongoloid slanting (due to disruption of
the frontozygomatic suture and inferior dis-
placement of Whitnall’s tubercle).
36
What is ecchymosis of the maxillary vestibule called
Guerin’s sign)
37
in ZMC fx make sure to check opeingin to see if impingement of the coronoid, also pupillary level these patients can have hypoglobus
38
What is the sequence of fixation and how many points are needed, what alignment is a good indicator of ZMC return
the frontozygomatic, zygomaticomaxillary,
orbital rim, and orbital floor regions. Minimum
two points of fixation are required.
Recommended sequencing of fixation:
– Fixate the frontozygomatic region first to
–
restore facial height of the complex.
– Fixate the zygomaticomaxillary buttress
–
region to restore facial projection and to
ensure that the medially rotated body is
back in its normal anatomical position.
– Fixate the orbital rim to define orbital vol-
–
ume and facial volume.
– The orbital floor should be managed last as
–
it is critical that the aforementioned sites
are placed back into alignment to prevent
enophthalmos and facial widening.
39
How to manage post ZMC enophthalmos.
Due to increase in orbital
volume or atrophy of fat. Posttraumatic enoph-
thalmos is difficult to manage. Requires place-
ment of space-occupying material such as bone
or prosthetic material behind the globe to dis-
place it anterior. Consider custom implant.
40
What are the signs of retrobulbar .
Rare but devastating either by
direct trauma to globe or retrobulbar hematoma.
In retrobulbar hematoma, the patient will have
pain, proptosis, elevated intraocular pressure, and
decrease in visual perception (first decrease in
red-green color perception followed by decreased
visual acuity)
41
How to perform a lateral canthotomy.
42
What are the bones of the orbit.
Orbital roof (two bones): Frontal and lesser
wings of sphenoid.
*
Lateral wall (two bones): Greater wing of
sphenoid and zygomatic bone.
*
Orbital floor (three bones): Maxillary bone,
zygomatic bone, and palatine bone.
*
Medial wall (four bones): Frontal process of
maxillary, ethmoid (lamina papyracea), lacri-
mal and sphenoid bones.
43
Where is the inferior orbital fissure, where is the infraorbital foramen, where is the superior orbital fissure.
*
Inferior orbital fissure gives rise to the infraor-
bital groove at about 2.5–3.0 cm posterior to
the orbital rim; exits the infraorbital foramen
about 5 mm below the infraorbital rim.
44
Know that picture of the superior orbital fissure.
45
What's In the inferior orbital fissure? how about the optic canal
sensory nerve V2,
parasympathetic branch of pterygopalatine
ganglion and inferior ophthalmic vein.
optic nerve, ophthalmic artery,
and sympathetic fibers.
46
Where is whitnalls tubercles, what's attached to it.
Whitnall’s tubercle: located 10 mm below the
FZ suture and 3–4 mm inside the lateral orbital
rim. Attachments (1) lateral horn of levator
aponeurosis, (2) lateral canthal tendon of the
eyelids, (3) Lockwood’s ligament, (4) check
ligaments.
47
What is the annulus of zinc
tendinous ring of fibrous
tissue at the apex of the orbit surrounding the
optic nerve that is the origin of the rectus mus-
cles of the eye.
48
Safe dissection what are the things distance from the anterior lacrimal crest
Safe Dissection: All measurements are from
an intact anterior lacrimal crest. Anterior eth-
moidal foramen 24 mm, posterior ethmoidal
foramen 36 mm, optic foramen 42 mm
49
What are the layers of the eyelid
skin, subcutaneous tissue,
orbicularis oculi, septum, tarsal plate, con-
junctiva)
50
OrbitalOrbital septum: dense connective tissue arising
from the orbital periosteum; forms the anterior
boundary of the orbit. 1–2 mm below the infra-
orbital rim, it fuses with an area of thickened
periosteum known as the arcus marginalis.
51
What is the dimensions of the tarsus, top and bottom, what are the glands
Tarsus: dense fibroconnective tissue; approxi-
mately 1–1.5 mm thick, approximately 25 mm
in horizontal length.
– Upper eyelid: 10–12 mm in height.
–
– Lower eyelid: 3–5 mm in height.
–
– Contains meibomian glands which form
–
lipid layer of tears.
52
What is the orbicular oculi. difference between palpebral and orbital muscles, what nerve
Orbicularis oculi (CN VII).
– Palpebral (pretarsal, preseptal): reflex eye-
–
lid closure.
– Orbital (covers orbital rims): forceful vol-
–
untary eyelid closure.
Levator palpebrae superioris (CN III): main
retractor of upper eyelid.
Muller’s (superior tarsal) muscle (sympa-
thetic): responsible for the tone of the upper
eyelid, ~2 mm of lift; minor retractor of the
upper eyelid.
53
Lavator palpebrae superoris innervated by what and what is the main function.
Levator palpebrae superioris (CN III): main
retractor of upper eyelid.
54
What is mullets muscle and what is it responsible for
Muller’s (superior tarsal) muscle (sympa-
thetic): responsible for the tone of the upper
eyelid, ~2 mm of lift; minor retractor of the
upper eyelid.
55
Where is whitewalls ligament
Supports the superior anterior eyelid; pro-
–
vides vertical support for the orbit.
– Inserts superomedially on the frontal bone
–
behind the trochlea; inserts superolaterally
near the frontozygomatic suture.
Key landmark that marks the transition
–
from levator muscle to aponeurosis (at the
junction of the levator muscle and
aponeurosis).
56
what is the main retractor of the lower eyelid, what is it an extension of.
Capsulopalpebral fascia: main retractor of the
lower eyelid; terminal extension of the infe-
rior rectus muscle.
57
What is the Lockwood pigment
Lockwood’s ligament.
– Lower lid counterpart to Whitnall’s liga-
–
ment (formed by conjoined fascia of infe-
rior rectus and inferior oblique muscles).
– Inserts on the medial and lateral canthal
–
ligaments as well as the bony orbital rim.
58
Where does the medial cantal ligmament attach
Medial canthal ligament (tripartite
attachment).
– Anteriorly inserts onto maxillary bone,
–
posteriorly onto posterior lacrimal crest,
superiorly onto orbital process of frontal
bone.
59
Where does nasolacrimal duct open into, and what is the hasher's valve
Nasolacrimal duct opens into the inferior
meatus of the nasal cavity 10 mm behind the
nasal aperture; reflux of tears is prevented by
Hasner’s valve.
60
anisocoria, what does monocular vs binocular diplopia indicate
Anisocoria – different sizes of the pupils.
Diplopia – double vision. May be monocular
(concern for retinal attachment or lens disloca-
tion) or binocular (unequal movement of eyes
usually due to edema or possible entrapment)
61
what is hyper tropia
Hypertropia – misalignment of eyes, a form of
vertical strabismu
62
How to evaluate for exophthalmos.
Evaluate for exophthalmos; Hertel (based off
zygomaticofrontal suture) or Naugle exoph-
thalmometers (based off of the frontal bone,
more useful when lateral orbital rim involved)
63
How to conduct the physical evaluation for cmc
Visual acuity (Snellen chart), visual fields
(Goldman chart, confrontation), pupils (affer-
ent pupillary defect), EOM (entrapment,
forced duction test to r/o incarceration of
orbital contents, diplopia in forward gaze is of
most concern), slit lamp (Wood’s lamp (cobalt
blue) for corneal injury), fundoscopic (vitre-
ous or retinal hemorrhage), tonometry pen
(pressures normal 10–20 mmHg).
64
What is white eye blowout fracture .What if they have bradycardia why?
Muscle entrapment. Ductions can illicit nau-
sea, vomiting, and bradycardia due to oculo-
cardiac reflex. In children, be cautious of a
“white eyed” blowout fracture.
65
What about management of orbit fracture, indications of repair
Large orbital fractures >50% orbital floor;
–
enophthalmos >2 mm, diplopia in primary
gaze.
66
Technique for transconjuncival incision
A corneal shield with ophthalmic-grade baci-
tracin/ocular lubricant is placed on the globe.
*
Local with vasoconstrictor is injected under
the conjunctiva to aid in hemostasis as well as
around the lateral canthus if lateral canthot-
omy is planned.
*
Using a 15 blade, a sharp incision is made
through the lateral canthus. The tip of an iris
scissor is placed inside the palpebral fissure,
extending laterally to the depth of the under-
lying lateral orbital rim (lateral extension
should not exceed 7 mm, ensuring a safe dis-
tance from the temporal branch of the facial
nerve). The scissors are used to cut horizon-
tally through the lateral palpebral fissure
(incising through skin, orbicularis muscle,
orbital septum, lateral canthal tendon, and
conjunctiva).
*
Using the lateral orbital rim as a stop, inferior
cantholysis is performed by turning the orien-
tation of the scissors vertically to incise the
inferior canthal ligament.
*
The conjunctiva is approached using blunt-tipped
pointed scissors to dissect through the
small incision through the conjunctiva, made
during the lateral canthotomy.
The conjunc-
tiva is bluntly undermined over the orbital
septum and extended as far medially (3 mm
away from the caruncle).
Scissors are then used to incise the conjunc-
tiva below the curvature of the tarsal plate. (2
5–0 nylon traction sutures may be used
through the cut edge of the bulbar conjunctiva
to assist in retraction and to hold the corneal
shield in place.)
The inferior bony orbit is palpated. With
retraction of the orbital contents and the lower
lid, the dissection continues to the orbital rim,
taking care to stay lateral to the lacrimal sac.
Periosteal elevators are used to strip the peri-
osteum over the orbital rim, anterior surface of
the maxilla, zygoma, and orbital floor.
A broad malleable retractor is placed to pro-
tect the orbit and to confine any herniating
periorbital fat.
After exploring the orbit, releasing entrapped
tissue, and identifying the bony landings, the
orbital floor is reconstructed to support the
globe contents.
Forced duction test is used to ensure uninhib-
ited mobility of globe.
A 4–0 Vicryl® is used to reattach the lower
limb of the lateral canthal tendon.
Subcutaneous sutures and 6–0 skin suture are
placed along the horizontal lateral
canthotomy.
Some surgeons reapproximate the bulbar con-
junctiva with 6–0 fast gut suture in a single or
running fashion suture.
67
How about for subciliary, what are the three approaches
The skin incision is made 2 mm below the
gray line. There are three approaches for
dissection down to the orbital rim with the
subciliary approach.
– 1. Skin.
–
– 2. Deep to the orbicularis oculi muscle
–
(skin-muscle flap).
– 3. Step dissection
It is more common to utilize a skin-muscle
flap, as it is less likely to lead to a lid mal-
position after healing. Violating the orbital
septum integrity leads to a higher risk of
vertical lid shortening.
A corneal shield with ophthalmic-grade baci-
tracin/ocular lubricant is placed on the globe.
*
The skin incision is made 2 mm below the
gray line.
*
The path of dissection deep to the orbicularis
oculi muscle includes the pretarsal orbicularis
muscle in the elevated skin muscle flap if the
skin incision is placed across the tarsus.
*
With the skin muscle flap and the step tech-
nique, maintaining the integrity of the orbital
septum is paramount. The incision through the
periosteum for entry into the floor of the orbit
is made beneath the infraorbital rim (3 mm
below).
*
A subperiosteal dissection is accomplished
posteriorly exposing the orbital walls.
*
Periosteal elevators are used to expose the
orbital floor, release entrapped tissue, and
identify stable margins.
*
A broad malleable retractor is placed to pro-
tect the orbit and to confine any herniating
periorbital fat.
*
After exploring the orbit, releasing entrapped
tissue, and identifying the bony landings, the
orbital floor is reconstructed to support the
globe and its contents.
*
Closure is usually performed in two layers.
The periosteum is reapproximated with a
resorbable suture. The skin is then closed with
a 6–0 non-resorbable or fast-resorbing suture
68
how to fix ectropion
Ectropion – due to shortening of the anterior
lamellae. May require tarsal strip.
69
how to fix entropion
Entropion – due to shortening of the posterior
lamellae. May require Quickert-Rathbun sutur-
ing technique (passing a gut suture through the
inferior fornix anteriorly toward the lashes).
Severe cases may require grafting with oral
mucosa.
70
what is sympathetic ophthalmia
Sympathetic Ophthalmia – injury-induced
autoantibodies to uveal tissue; ~80% occur
within 3 months.
*
Treatment options include:
– Enucleation: entire removal of globe with-
–
out rupture.
– Evisceration: leave the sclera +/− cornea.
–
– Exenteration: entire contents of the orbit
71
How to manage retrobulbar hemorrhage, medically and surgically
Manage medically with IV infusion 20% man-
nitol 2 g/kg to shrink the vitreous humor, acet-
azolamide (Diamox ®) 500 mg bid, or
steroids.
Manage surgically with lateral canthotomy
with cantholysis.
72
What is Jones test 1 and 2, how and when do you repair, when primary when secondary repair
Jones I test: few drops of fluorescence dye or
propofol in the lower conjunctival sac, observe
for fluorescein/propofol in the nose. If not
identified, perform Jones II test.
Jones II test: irrigate the punctum and inject
fluorescein into the (SAC) puncta/canaliculi.
– If fluorescein is seen, then the blockage is
–
after the lacrimal sac; if not, then the block-
age is near the punctum or canaliculus.
If a laceration is present and visible, early
repair is advocated, but reasonable to wait
3–6 months if no laceration is present.
Primary repair: dilate with bowman probe,
place stent (Crawford tube, Jackson tube)
through the puncta and nasolacrimal duct
opening in the nose, suture both ends with 8–0
PDS sutures, and leave the stent for 3 months.
Secondary repair: dacryocystorhinostomy; the
goal is to create a bony window between the
lacrimal sac and nose.
73
How to treat corneal abrasions.
– Symptoms: pain, tear-
ing, photophobia, foreign body sensation, treat-
ment with topical antibiotics.
74
Hyphema, and its grade, and how to manage, what are its complications
Bleeding from torn vessels at the
root of the iris in the anterior chamber; signs/
symptoms: positional blurred vision,
photophobia.
*
*
*
Grade 1: ¼ of anterior chamber; Grade 2: ½;
Grade 3: ¾; Grade 4: complete coverage of
the anterior chamber, aka blackball or 8-ball
hyphema.
Manage with atropine 1% ophthalmic drops
bid/qid (dilates pupil and immobilizes the iris
to prevent further bleeding), timolol ophthal-
mic drops bid (beta-blocker to decrease intra-
ocular pressure, acetazolamide 500 mg PO bid
(carbonic anhydrase inhibitor, IOP > 35 mm
Hg), steroids, bed rest with HOB elevated.
Complications: 2.5% to 38% re-bleeding most
common 2–5 days post-injury; glaucoma after
one year; corneal blood staining in 5%
75
What is Marcus Gunn pupil
Afferent Pupillary Defect (Marcus Gunn
pupil) – Swinging-flashlight test: light in the
affected eye produces mild to no consensual light
pupillary reflex; then swinging light to normal
eye produces equal constriction; then swinging
light to affected eye produces dilation during
direct light stimulation.
76
Traumatic Optic Neuropahty, what is it and why, how to treat
Traumatic Optic Neuropathy – Decreased
vision in the affected eye; ipsilateral afferent
pupillary defect.
*
*
Thought to be due to vascular insufficiency;
goal is to reduce microvascular spasm and soft
tissue edema.
Treatment with large dose steroids (methyl-
prednisolone 30 mg/kg IV loading dose, then
5.4 mg/
77
Treating traumatic mydriasis
Pupillary dilation due
to interruption of the parasympathetic
innervation.
*
Results in anisocoria; treatment with 2% prilo-
caine; may resolve over several days or week
78
Treatment of traumatic iritis
Traumatic Iritis – Inflammation of the anterior
chamber of the eye, onset within 3 days of trauma.
*
*
Symptoms: dull pain, tearing, and
photophobia.
Treatment with cycloplegic agents: scopol-
amine 0.25 or cyclopentolate 2%
79
What is Hornor syndrome, how to diagnose
Horner’s Syndrome – injury to sympathetic
nerves supplying the globe.
*
*
Triad of signs: (1) miosis (unopposed para-
sympathetic), (2) eyelid ptosis (decreased
Muller’s muscle tone), (3) anhidrosis (sweat
glands).
Diagnosis: 4% cocaine drops to the affected
eye fails to dilate compared to the unaffected
pupi
80
Superior orbital fissure syndrome, who needs to be consulted
Ophthalmoplegia (CN III, IV, VI), lid ptosis (CN
III), mydriasis and loss of direct pupillary light
reflex (CN III parasympathetic fibers). Treatment
is dependent on etiology. Retrobulbar hematoma
(see above). If superior orbital fissure narrowed in
the setting of fractures, then surgical intervention
for the displaced fracture segments is required. IR
may be indicated in the setting of a carotid-cav-
ernous fistula. Ophthalmology and neurosurgery
should be consulted as an intracranial/transeth-
moidal approach may be indicated should decom-
pression in the posterior orbit be necessary.
81
Orbital Apex Syndrome
Orbital Apex Syndrome – Superior orbital fis-
sure syndrome + injury to CN II (loss of vision
and direct and consensual pupillary light reflex).
Treatment is dependent on etiology. Retrobulbar
hematoma (see above). IR may be indicated in
the setting of a carotid-cavernous fistula. If supe-
rior orbital fissure narrowed in the setting of frac-
tures, then surgical intervention for the displaced
fracture segments is required. Ophthalmology
and neurosurgery should be consulted as an
intracranial/transethmoidal approach may be
indicated should decompression in the posterior
orbit be necessary
82
Which bones are involved in an NOE fracture
NOE anatomy – the NOE complex consists of the
nasal bones, frontal processes of the maxilla,
nasal process of the frontal bone, and the medial
orbital wall (comprised of the lacrimal bone and
ethmoid bones)
83
What is the Mason and Markowitz Classifications of NOE
Type I – no comminution of the central frag-
ment and the tendon is intact.
Type II – comminution of the central fragment
and the tendon is intact.
Type III – severe comminution of the central
fragment and the tendon is avulsed.
84
NOE what will you see on physical examination, normal intercanthal distances
Depressed nasal dorsum (saddle nose
deformity).
Crepitus.
Telecanthus – intercanthal distance should be
coincident with the width of the alar bases.
Clinician would perform the bow-string test to
confirm disruption of the medial canthal ten-
don. Intercanthal distance varies between
ages, races, and gender. Normal range for a
white adult is 28–35 mm. Intercanthal dis-
tances greater than 35 mm are suggestive of
medial canthus involvement and 40 mm or
more are diagnostic for traumatic telecanthus.
Almond-shaped eyes – due to the detachment
of medial canthus.
Periorbital edema and ecchymosis.
Anosmia – damage to cribriform plate leading
to damage of olfactory nerves.
Paresthesia/anesthesia along distribution of
the infraorbital nerve.
Epiphora – occurs due to obstruction within
the nasolacrimal apparatus. Jones I and
Jones II tests. Early onset may be due to
swelling.
Enophthalmos (remember the medial wall
being involved can also lead to increased
orbital volume).
Epistaxis.
Rhinorrhea – CSF leak noted as thin blood-tinged
discharge from nose. Test for beta-2
transferrin. May also send sample for glu-
cose and chloride level. Chloride is usually
greater and glucose is less than serum. Halo
test involves placing a drop of the bloody
rhinorrhea on filter paper and seeing a center
of blood and a straw-colored halo
85
CSF vs serum
May also send sample for glu-
cose and chloride level. Chloride is usually
greater and glucose is less than serum
86
What vector for NOE canthopexy
Type III fractures require a canthopexy with a
posterior superior vector.
87
How to treat nasal dorsal augmentation recon
Treatment is commonly done with the outer
cortex of the calvarium as it is relatively flatand easily recontoured. It is stabilized by a
small bone plate.
Extension of bone graft should reach region of
lower lateral cartilages for nasal tip support.
88
Management of the avulsed medial cantal tendon vis canthopexy, what are the complications and treatments, how to place a stent?
*
*
Transnasal wiring technique. The vector of
fixation is posterior and superior to the lacri-
mal fossa.
Suturing the tendon to a miniplate in the NOE
region. A non-resorbable suture is used and
the vector of fixation is posterior and superior
to the lacrimal fossa.
Mitek anchoring procedure – use of suture
anchoring device for management of medial
canthal tendon. The vector of fixation is poste-
rior and superior.
Dacryocystitis – infection of lacrimal sac due to
obstruction. Treatment with antibiotics such as
penicillin-based drugs.
Epiphora – first attempt lower lid massage; if
no improvement, dacryocystorhinostomy should
be considered. In this procedure, an incision is
placed 6 mm from the medial canthal angle and
dissection is carried to the lacrimal sac. An H
incision is made in the nasal soft tissue and lacri-
mal sac. The posterior flaps are sutured together.
The puncta are intubated with a Crawford tube
and passed through the openings of the nose. The
ends of the Crawford tube are tied and the ante-
rior flaps of the nasal mucosa and lacrimal sac are
sutured together. The orbicularis muscle and skin
are closed. The stent is left in place for
3–6 months.
89
What's in the kiesslebach plexus
anterior ethmoidal artery, posterior ethmoidal
artery, nasopalatine artery, and septal branch
of the superior labial artery; the plexus is the
89
How to close a nose with closed reduction
Closed reduction involves administration of a
vasoconstrictor into the nasal cavity and then
digitally, or through the aid of appropriate
instrumentation (e.g., Boise elevator), reduc-
ing the nasal bones in their appropriate pre-
morbid state
90
Nasal septum is thick posteriorly along the
bony junction with vomer and ethmoid
bones.
91
When to remove internal and external nasal packings
External and internal packings are typically
removed within the first 7 days following
repair.
92
chronic use of
nasal decongestants interfere with normal
nasal mucosal thickness and increase the need
for frequent usage (rhinitis medicamentosa,
aka rebound nasal congestion
93
How long with further obstruction should you perform a post traumatic rhino, also when should you perform after initial surgery.
ersistent nasal airflow obstruction and/or
nasal complex deviation beyond 2–3 months
will require a post-traumatic rhinoplasty.
Full thickness laceration, especially along the
nasal tip, can compromise the vascularity of
the nasal tip; therefore, open structure rhino-
plasty should be delayed for 12 months to
avoid tip necrosis
94
800-1600 lbs of force for what fracture.
Frontal Sinus fracture
95
15% of population has a true nasofrontal duct faciliatining frontal sinus drainage into where ., where does the rest of people drain.
15% of the population has a true nasofrontal
duct facilitating frontal sinus drainage into the
middle meatus of the nose. The remaining
population drains via the hiatus semilunaris to
the nasal frontal tract.
96
What's the classification for frontal sinus
Gonty’s Classification
*
*
*
*
Type 1 – isolated anterior table.
Type 2 – anterior and posterior table
fractures.
Type 3 – posterior table fracture.
Type 4 – comminuted fracture.
97
What can also be evaluated with frontal sinus fracture
Head CT scan is important for the evaluation
of pneumocephalus, extradural hematoma,
and subarachnoid hemorrhage, which are
commonly associated with frontal sinus frac-
ture and necessitate neurosurgical consult.
Cervical spine evaluation and potential CT or
MRI imaging is important as a cervical spinal
fracture or ligamentous injury should be ruled
out prior to definitive management of the frac-
ture to prevent spinal cord injury during
patient positioning and/or intubation.
98
What is the physical exam for frontal sinus fracture.
Glabellar swelling.
Depression of frontal bone (not always visible
due to swelling/hematoma).
Supraorbital numbness.
Eyelid ecchymosis.
Air emphysema/crepitus.
Rhinorrhea – present as a clear or strawberry-colored
fluid; however visual inspection is
often limited due to the presence of blood and
nasal secretions.
– A halo test, where the fluid is dropped onto
–
a tissue paper can reveal the presence of
CSF by formation of a clear ring around the
blood.
– Samples of CSF will show high chloride,
–
low potassium, and low glucose concentra-
tion (>30 mg/dl) compared to normal
serum.
– Intrathecal fluorescein dye injection with
–
imaging.
– The definitive test for CSF rhinorrhea is the
–
beta-2 transferrin assay. Collect nasal
secretions in sterile tube and send to the
lab. Can be held at room temperature for
1 week without compromise of sample.
The assay is based on a western blot, which
takes 4 days to process. Requires 5 cc of
fluid collection for accurate diagnosis.
– β-trace protein (βTP) may also be used as a
–
diagnostic marker, but not reliable in
patients with renal deficiency or bacterial
meningitis
99
How is a beta 2 transferring assay done and how long does it take and how many cc
1 week without compromise of sample.
The assay is based on a western blot, which
takes 4 days to process. Requires 5 cc of
fluid collection for accurate diagnosis.
100
How to manage CSF leaks
f the CSF leak does not resolve with observa-
tion within 7 days, neurosurgical management
may include placement of a lumbar drain to
decrease the intracranial pressure or direct
repair of the dural tear (if the drain is not
successful).
101
Indications for treatment of anterior table fractures, what are the approaches
Treatment of anterior table fractures is dic-
tated by the aesthetic deformity secondary to
the fracture. In the case of nondisplaced and
minimally displaced fractures, the patient can
be treated with observation alone.
Decongestants may be indicated to aid in
sinus system pressure relief. Consider 6 week
reimaging to ensure fluid levels are dissipated
and frontal duct system is intact.
Typically, displacement of the anterior table is
defined as 1–2 mm, or greater than the width
of the anterior table; n the case of an open frontal sinus frac-
–
ture, the existing soft tissue laceration(s)
can typically be used to expose the fracture
and extended as needed to provide ade-
quate visualization.
– Options for exposure of closed frontal
–
sinus fractures include the coronal and
supraorbital approaches.
– Additional options for exposure that are
–
used by some authors include the frontalis
rhytid approach.
– Endoscopically assisted procedures have
–
also been described with anterior wall frac-
tures without duct involvement
102
How to manage Nasofrontal duct involvement
The lining of the sinus floor, containing the
mucosa of the nasofrontal ducts, is then ele-
vated, inverted, and placed back into the
infundibulum to obstruct the outflow tract.
The sinus floor is then typically packed with
local tissue to ensure separation of the inverted
mucosa from the sinus. Typically, a small
piece of temporalis fascia or muscle is used,
but a thin piece of calvarium can also be har-
vested and trimmed for this purpose. Synthetic
fibrin sealants are an alternate option for
occluding the nasofrontal ductThe optimal method for obliteration of the
remaining free space is controversial. The
most common materials used are abdominal
fat or iliac crest bone. Additional autologous
tissues that are commonly used include fascia,
muscle, and pericranium.
103
Ways to occlude the nasofrontal ducts to obstruct the outflow tract., how about for obliteration? How about synthetic materials for obliterations
remaining free space is controversial. The
most common materials used are abdominal
fat or iliac crest bone. Additional autologous
tissues that are commonly used include fascia,
muscle, and pericranium.
The use of synthetic materials such as
hydroxyapatite, methyl methacrylate, bio-
glass, gelfoam, etc. is less common but has
also been described [6, 7]. These synthetics
are not recommended due to the risk of infec-
tion from poor vascularity.
Another commonly used and accepted tech-
nique for sinus obliteration is spontaneous
osteogenesis, which occurs when the sinus
cavity is left empty.
104
management for posterior table fracture without CSF leak
A non-displaced fracture with a small CSF
–
leak may be observed for up to 7 days for
resolution of the CSF leak.
– Conservative treatment includes bed rest,
–
stool softeners, elevation of the head of bed
between 35–45 degrees, and sinus precau-
tions. CSF leaks greater than 72 hours may
require a lumbar subarachnoid drain. Those
leaks lasting greater than 7 days require
surgical interventio
Frontal sinus obliteration with or without
–
cranialization.
– Frontal sinus obliteration alone can be con-
–
sidered in cases with a displaced posterior
table fracture that involves less than 25% of
the posterior table, has minimal to no com-
minution, and does not have an associated
CSF leak
105
What are the operative treatments for posterior table fracture.WHen do you cranialize
Frontal sinus obliteration with or without
–
cranialization.
– Frontal sinus obliteration alone can be con-
–
sidered in cases with a displaced posterior
table fracture that involves less than 25% of
the posterior table, has minimal to no com-
minution, and does not have an associated
CSF leak
106
what are he approaches to a frontal sinus fracture
In the case of open fractures, the most com-
mon approach is an extension of the laceration
to obtain adequate exposure.
The most common approach used for closed
frontal sinus fracture is the coronal (bitempo-
ral) approach.
Additional options include the supraorbital,
frontalis rhytid approach, the endoscopic
approach, and combined open and endoscopic
techniques.
The coronal approach provides the best visu-
alization and is ideal for bilateral frontal sinus
fractures that necessitate a wide exposure.
– This approach has an acceptable cosmetic
–
result and the bulk of the incision is well
hidden within the patient’s hair.
– Another advantage of this approach is that
–
it facilitates harvesting of cranial bone
graft if needed.
107
Describe the c coronal approach
onsideration for hairline and lack thereof:
The incision normally curves anterior at the
vertex 5 cm behind the hairline. In the bald
patient, consider a more posterior incision.
Access is created the more inferior the inci-
sion extends, if the arches require exposure
(incision may extend to the inferior portion of
the ear lobule).
The traditional initial incision is extended
sharply through skin, subcutaneous tissue, and
galea between the temporal lines exposing the
loose areolar plane. Blunt dissection is used to
elevate in all directions, but primarily
anterior.
Extension below the temporal line can be
carefully completed using the subgaleal plane
as a guide to bluntly dissect alongside the
anterior helix. A sharp incision is made down
to the instrument.
Following the incision, additional hemostasis
can be obtained with Raney clips.
Continued exposure should be performed in
the areolar tissues of the subgaleal plane. This
can be developed easily with blunt dissection.
Lateral tension of the flap is due to the remain-
ing attachments to the temporalis fascia and
should be relieved to allow for anterior dis-
placement of the flap.
Approximately 2–3 cm superior to the supra-
orbital rims, the pericranium can be incised
and the dissection can proceed in a subpericra-
nial plane to obtain exposure
A periosteal elevator can be used at this
point to continue the dissection and care
should be taken to preserve the integrity of
the pericranium for use as a vascularized
flap if desired.
If additional exposure is needed, the superfi-
cial temporalis fascia can be excised at the
root of the zygomatic arch meeting the hori-
zontal incision above the orbital rims at a
45-degree angle. The temporal branch of the
facial nerve should be safely located on the
undersurface of the temporoparietal fascia.
The orbital foramen/notch may be osteoto-
mized to allow release of the neurovascular
bundles and further retraction.
Access to subcondylar region can be reached
through a coronal flap by detachment of the
masseter muscle or osteotomizing the arch
with attachment of the masseter.
108
What is the follow up, what are the complications
Weekly follow up for 1 month. Every 3 months
for the first year and every year up to year 5. CT
scans are recommended at years 1, 2, and 5 or if
symptomatic.
Meningitis – Inflammation of the arachnoid
membrane and the pia mater extending
throughout the subarachnoid space, brain, spi-
*
nal cord, and ventricles. Acute fever, head-
ache, stiff neck, and confusion are common to
meningitis. Kernig sign (inability to flex the
leg with thigh at a right angle to the trunk) or
Brudzinski sign (flexion of hips and knees
when neck is flexed) may be present 30% of
the time. Diagnosis made with CT scan of the
head to rule out a mass or lesion; blood cul-
tures and CSF examination for protein, glu-
cose, cell count; and gram stain. Antibiotics
are empirically used until cultures available
with neurosurgical consultation.
Mucocele and Mucopyocele – Mucoceles
form from retained sinus mucosa with com-
promised sinus ventilation leading to mucous-filled
lesions. A mucopyocele forms when the
mucoceles are infected. Treatment involves
obliteration of the sinus.
Intracranial Abscess – Patients will normally
have a subacute onset of illness and not appear
toxic. Common signs are mental status
changes, focal neurologic deficits, fever, nau-
sea/vomiting, and seizures. Treatment involves
neurosurgical consultation, parenteral antibi-
otics (e.g. third generation cephalosporins)
with possible craniotomy for aspiration/drain
placement.
Cavernous Sinus Thrombosis – Clinical signs
include headaches, ptosis, ophthalmoplegia,
paresthesia of ophthalmic and maxillary
branch of CNV, papilledema, and periorbital
edema. Imaging best visualized with MRI
with gadolinium but contrast enhanced head
CT is also valuable. Treatment includes, broad
spectrum antibiotics, anticoagulation with
heparin, and sinus drainage. High dose ste-
roids are controversial but may reduce cranial
nerve dysfunction.
Contour Deformity – Allow for swelling to
resolve completely. May correct with bone
grafting, bone cement, or custom alloplastic
implants.
109
How to treat intracranial abscess
Common signs are mental status
changes, focal neurologic deficits, fever, nau-
sea/vomiting, and seizures. Treatment involves
neurosurgical consultation, parenteral antibi-
otics (e.g. third generation cephalosporins)
with possible craniotomy for aspiration/drain
placemen
110
What do you see with cavernous sinus thrombosis
Clinical signs
include headaches, ptosis, ophthalmoplegia,
paresthesia of ophthalmic and maxillary
branch of CNV, papilledema, and periorbital
edema. Imaging best visualized with MRI
with gadolinium but contrast enhanced head
CT is also valuable. Treatment includes, broad
spectrum antibiotics, anticoagulation with
heparin, and sinus drainage. High dose ste-
roids are controversial but may reduce cranial
nerve dysfunction.
111
Take spine films with Pan Facials 20% associated
112
What is the vertical and horizontal buttresss
The vertical buttresses run in a cranial to cau-
dal direction and are important for maintaining
facial height. From anterior to posterior, they
include the nasomaxillary, zygomaticomaxil-
lary, pterygomaxillary, and posterior mandibu-
lar buttresses. The pterygomaxillary buttress is
the only one that is not typically surgically
reconstructed because it is inaccessible.
The horizontal buttresses run in an anterior to
posterior direction and are important to main-
tain facial projection. From inferior to supe-
rior, these include the mandibular, maxillary,
zygomatic, and frontal buttresses
113
How to Bottom up and inside out
ATLS protocol starting with a primary survey
and evaluation of life-threatening problems.
Airway protection, perfusion, and hemody-
namic stability are confirmed or established.
Medical history should be obtained when pos-
sible, either from the patient or family and
friends.
As previously described for the subunit, a full
head and neck exam should be completed.
Patient should be inspected for rhinorrhea and
otorrhea. Cerebrospinal fluid (CSF) rhinorrhea
and/or otorrhea will present as a clear or
strawberry-colored fluid.
Oral examination to identify integrity of
occlusion, which can be useful as a stable base
for reconstruction
114
How about the top down approach
Use mandible as the foundation for
reconstruction.
Typical Surgical Sequence:
*
*
*
*
*
*
*
*
Maxillomandibular fixation – consider prefab-
ricated splint, made from stone models, for
comminuted dentate segment fractures.
Mandibular bony/ramus/angle/symphysis
fractures. Make sure to keep pressure at the
angle of mandible to prevent splaying and
increasing of lower facial width. Treatment of
symphysis fractures may require over bending
the plate to prevent splaying of the lingual cor-
tex (always treat the dentate segment first).
Condylar fractures if indicated to restore verti-
cal height. If one condyle is intact, it may only
require elastic training after period of maxil-
lomandibular fixation.
Treat the zygomaticomaxillary complex next.
Fixate the frontozygomatic region first to
restore facial height of the complex. Fixate the
zygomaticomaxillary buttress region to restore
facial projection and to ensure that the medi-
ally rotated body is back in its normal anatom-
ical position. Fixate the orbital rim to define
orbital volume and facial volume. The orbital
floor should be managed last as it is critical
that the aforementioned sites are placed back
into alignment to prevent enophthalmos and
facial widening.
Naso-orbitoethmoid complex.
Frontal sinus.
Implants/augmentation – such as dorsal struts.
Soft tissue support/repair.
115
What is tetanus
etanus is a neuromuscular disease caused by
Clostridium tetani, a spore forming, gram-positive, strictly anaerobic bacillus found in
soil, intestines, and feces.
Spores germinate to produce exotoxin tetano-
spasmin, a potent neurotoxin that is carried to
the nerve terminals blocking spinal cord
inhibitory neurons, which causes trismus,
spasm of facial expression muscle (Tetanus prophylaxis should be evaluated for
contaminated wounds.
Tetanus toxoid should be administered if the
patient has not been administered vaccina-
tion over 10 years, failed to complete a pri-
mary tetanus vaccination of at least three
doses, or has an unclean wound and has not
received tetanus vaccination in over 5 years
116
When should wounds of the face be closed by, inoculation by number of bacteria is what per gram of tissue.
Which bacteria most commonly contaminate the skin.
Due to the rich vascularity of the face, facial
wounds that are clean can be closed within
48 hrs. This differs from non-head wounds
that should be closed no more than 19 hours
after insult.
Inoculation of infectious organisms must
exceed 10 organisms/gram tissue for gram-positive
and gram-negative bacteria. The num-
ber of bacteria present is of more concern than
the species.
Staphylococcus and Streptococcus are the
species most involved in the contamination of
facial skin.
117
What irrigation pressure for removal of bacteria
ulsatile (high pressure) irrigation requires
pressure of 7 lb. Psi to remove adherent bacte-
ria with a balanced salt solution or a scrub
brush.
Povidonulsatile (high pressure) irrigation requires
pressure of 7 lb. Psi to remove adherent bacte-
ria with a balanced salt solution or a scrub
brush.
Povidon
118
What is langers lines of skin tension.
Wounds should be closed in a tension-free
manner, taking into account the phases of
wound healing and Langer’s lines of skin
tension.
119
When should sutures be removed, what cause scars post suture. What about for subcuticular removal
Sutures recommended to be removed in the
face in 7–10 days, and in thin tissue areas such
as eyelids in 3–5 days (tensile strength
regained is only 5–10% at this time point).
Causes of marks include (1) epithelialization
due to extended stay of sutures, (2) tissue
necrosis secondary to tension across suture
line, and (3) reactive suture type.
Subcuticular sutures can remain up to
4 weeks.
120
What is in dog and feline bites. How about for human diets
Dog and feline bites – Pasteurella multocida,
Streptococci, and Staphylococcus aureus.
Domestic dogs on average have a biting force
of 320 lbs. of pressure [10].
Human Bites – Eikenella corrodens,
Staphylococcus Aureus, Haemophilus influen-
zae, and Corynebacterium. Additionally, con-
sideration should be given to Hepatitis B and
C, herpes simplex virus, syphilis, tuberculo-
sis, and HIV, which can be transmissible
through human bite
121
How to treat with wounds with cartilage, what if allergic to penicillins
Wounds with exposed cartilage are most likely
to become infected.
Treat with high-pressure irrigation with nor-
mal saline.
Antibiotic coverage of choice is amoxicillin
and clavulanic acid (Augmentin®). If penicil-
lin allergic, then consider doxycycline and
metronidazole.
122
What about rabies
Rabies is an important consideration following
an animal bite. It is a viral infection of single
stranded RNA virus (rhabdovirus family).Post exposure prophylaxis includes involved
passive immunity by giving 20 IU/kg human
rabies immunoglobulin directly around the
wound and any remaining volume intramus-
cularly [11]. 1 ml of human diploid cell vac-
cine or purified chick embryo cell vaccine
should be given intramuscularly on days 0, 3,
7, 14, and 28.
123
Where does the parotid duct and buccal branch lie. What do you do for duct injury at sites A,B, and C
Buccal branch of the facial nerve often runs
together with the parotid duct. Can estimate the
course of the duct by drawing a line between
the tragus and midportion of the upper lip.
Van Sickels divided Stensen duct in three
distinct sites (Fig. 7.6) [13]. Site A corre-
sponds to the most proximal part of the duct,
intraglandular. Site B corresponds to the part
of the duct that is located superficial to the
masseter muscle. Site C corresponds to the
part of the duct located anterior to the mas-
seter muscle and subsequently enters the
buccinators.
The duct terminates intraorally,
adjacent to second maxillary molar. If injury
is at sites B or C, attempt to identify stumps
for repair. For site A injuries, treatment is
only closure of parotid capsule; these injuries
have lower complication rates.
124
What is a sialocele, how to treat
Formed by leak of saliva into glandular or
–
periglandular tissue.
Check to ensure saliva via amylase levels
–
>10,000 u/l is confirmatory.
– Treatments include: pressure dressing and
–
multiple aspirations with or without antisi-
alogogues (propantheline
secondary duct repair, intraoral
fistula creation (dochoplasty), low radia-
tion (1800 rad/treatment for more than
6 weeks total of 30 Gy) and for non-responders
Botox (10–20 units of botox-
A), superficial or total parotidectom
125
How to do stensen duct repair and when
Repair should be done preferably in the first
24 hrs.
*
*
*
*
*
*
Anesthesiologist to avoid sympatholytics or
only short acting agents.
Use ketamine to encourage salivary flow.
Identify distal end with 20–22-gauge silastic
tube via the opening of the duct, which can be
identified with a lacrimal probe.
Identify proximal end of duct, may be eased
by parotid massage to encourage salivary flow.
Repair duct with 6–0 nylon.
Stent to be kept in place 5 days up to 3 weeks
and given sialogogues (lemon drops) to pre-
vent scarring.
126
What line posterior should a facial nerve be attempted.
Facial nerve repair should be attempted poste-
rior to a line drawn perpendicular to the lateral
canthusRepair within 72 hours, prior to Wallerian
degeneration and loss of ability to identify
nerve with stimulator
127
How to do a facial nerve repair
repair the epineurium
with 9–0 nylon on a GS-8 needle. Use threesutures to obtain anastomosis. Fibrin glue and
collagen tubes have been used to aid
anastomosis.
128
Repair of submandibular gland/ submandibular fistula
Repair of duct normally unnecessary as will
form a fistula in the floor of mouth. If subman-
dibular fistula forms, serial aspirations with
pressure bandage will normally resolve this. If
not, the submandibular gland should be
removed.
*
Sialodochoplasty done for pathological resec-
tions that include the floor of the mouth.
129
Lacrimal apparatus repair
Anesthetize the medial canthus, dilate punc-
tum with dilator, and pass silicone intubation
stent (Crawford tube); pigtail probe is passed
through the intact punctum and canaliculus to
identify the transected portion.
*
Cannulate upper and lower punctum and
thread stent into nose (below inferior turbi-
nate), cut the steel rods, and tie a knot. Allow
3 months to heal, remove tube through the
segment visible in the corner of the eye
130
Why do moist wounds heal faster
Wounds kept moist heal faster than those
exposed to air:
– Keratinocytes migrate sooner.
–
– Prevents hypoxia which drives angiogene-
–
sis and retention of growth factors.
– Affords protection against exogenous
–
organisms.
– Retains water and proteolytic enzymes,
–
which debride the wound.
131
when to use collagen scares
shown to suppress fibroblast activity and
decrease capillary activity and collagen depo-
sition leading to decreased dermal thickness
(decreases scarring). They are to be used after
epithelialization has occurred
132
how to treat keloids
Hypertrophic scars develop within the borders
of the wound. Keloids are scars that extend
outside of the wound borders. Treatment
includes intralesional steroids that can be
started at 1 month post-op (e.g. Triamcinolone
40 mg/ml, 0.2 ml given every 3 weeks for
3 months). Aggressive injections can lead to
significant atrophy.
133
Name skin scar treatments
Silicone sheeting, flashlamp-pumped pulsed-dye
laser 585 nm or 1064 nd:YAG non-ablative
laser, dermabrasion at speed of
35,000 rpm with diamond fraise burrs of
medium course can also be used.
134
What to used to suture ear cartialge and what abx to cover
Fluoroquinolones are prudent for inju-
ries that involve the cartilage to cover
Pseudomonas aeruginosa. However, it is
toxic to developing cartilage and should not
be given to patients under 18 years of age.
If perichondritis develops, assume it is from
this pathogen.
*
The ear is extremely vascular and only requires
small pedicle for revascularization.
*
Elastic cartilage found in the ear, which is
relatively avascular, is not commonly sutured
as this may devitalize the area. If suture is
required, then a fine chromic suture is
recommended
135
What to do for partial avulsion of the ear, what is the baud technique
f there is partial avulsion, classically the
Mladick technique (retroauricular pocket) is
performed: de-epithelize amputated auricle,
perform anatomic cartilage reattachment, and
bury into retroauricular pocket. The second
stage (2 weeks later) is cartilage elevation and
split thickness skin graft.
The Baudet technique for ear repair [14]:
amputated auricle’s posterior surface is de-https://t.me/DentalBooksWorld
7 Maxillofacial Trauma
211
*
*
epithelized, cartilage fenestrated, retroauricu-
lar pocket raised, and anterior pinna skin
sutures placed. Second stage: ear elevation
and split thickness skin graft.
136
How long to bolster auricular hematoma.
Early treat-
ment with needle evacuation (incision and
drainage for late treatment). A bolster dressing
should be left in place for 7 days.
137
How to treat anterior bleed, how about posterior bleed
Exam should be performed after achieving
profound anesthesia and vasoconstriction for
visualization. Anesthesia and vasoconstriction
for exam can be achieved with 4–10% cocaine
topical solution (max 1 mg/kg for infant or
2–3 mg/kg for adult). Another option is utiliz-
ing local anesthesia with oxymetazoline-soaked
neuro sponges.
*
Septal hematomas are drained with small
mucosal incision or needle drainage. Nasal
pack or septal stent secured with a multiple
pass 4-O suture technique is utilized to pre-
vent recurrence.
Finger compression for 10 minutes.
–
– Topical vasoconstrictors.
–
– Silver nitrate application.
–
– Nasal sponge cut to 4–6 cm (from 10 cm
–
sponge) coated in petroleum jelly removed
in 48 hrs.
– 1/2 inch petroleum jelly soaked gauze
–
removed after 48 hrs.
– Balloon tamponade coated with Sodium
–
Carboxymethylcellulose, e.g., Rapid Rhino
© (to aid in gel coat and to encourage
platelet aggregation) soaked 30 seconds in
sterile water (not normal saline as it may
interfere with hydrocolloid fabric). Fill the
bladder of the rhino with air from a syringe
and monitor tactile feedback of pilot cuff
(cuff becomes rounded and feels firm).
Remove in 24–72 hours.
Control of a posterior bleed is most com-
monly managed with the use of a 14 French
Foley catheter with a 30 ml balloon. Fill itwith 10–15 ml saline. Retract the Foley so the
balloon is wedged and add 3–5 ml of more
saline. Remove in 3 days. Of note, some doc-
tors use air versus saline due to aspiration risk
if the catheter were to rupture. On the con-
trary, leakage of air renders the catheter
ineffectiv
Nasopulmonary reflex – mediated by trigemi-
nal and vagal nerves. Can be seen in patients
with COPD, advanced pulmonary or cardiac
conditions. Nasal packing can cause a 15 mm
Hg drop in arterial oxygen pressure
137
What's in woodruff plexus
e sphe-
nopalatine artery and the posterior pharyngeal
artery (
138
What is the naeopulmonary reflex
Nasopulmonary reflex – mediated by trigemi-
nal and vagal nerves. Can be seen in patients
with COPD, advanced pulmonary or cardiac
conditions. Nasal packing can cause a 15 mm
Hg drop in arterial oxygen pressure
139
What do you do if packing fails
If packing measures fails, then consider
endoscopic sphenopalatine artery ligation
(EPSAL) for a posterior bleed or anterior
ethmoid artery ligation for anterior bleed.
Extensive bleeding may require ligation of
both regions.
140
What is the defect of the upper and lower lip that can be repaired primarily , how about with abbe or estlander flap, what about larger
Defects of up to 25% of the width of the upper
lip can be closed primarily, and 30% of the
lower lip.
*
Misalignment of 1 mm of the vermillion bor-
der can be detected by the human eye.
*
Intermediate defects up to 2/3 of the upper or
lower lip can be reconstructed with either the
Abbe flap or the Estlander flap.
*
Larger defects may require Karapandzic flap,
Gilles flap, or a Webster-Bernard flap.
141
Where do you get premature ossification if you open a needs nose
ated with premature ossification of the septo-
vomerine or nasoethmoid suture. This may
lead to a restriction in midface growth.
142
Orbital roof fractures in children are more common <7 yaears, lower is >7 years due to why
Secondary to a proportionally larger cranium
and a lack of rudimentary sinuses present.
143
What is white eyed orbital floor fractures, when should it be intervened
Assess for the presence of “white eyed” orbital
floor fractures (no subconjunctival hemor-
rhage or overt signs of orbital trauma is seen)
that can result in muscle necrosis of the infe-
rior rectus muscle due to entrapment. The ocu-
locardiac reflex may be seen in this patient
population (intractable nausea and vomiting,
bradycardia, and occasionally syncope.)
*
Early intervention is crucial (2 days
maximum).
144
How many points of fixation for pediatric non comminuted zmc fractures
Displaced fractures require an open approach
and one-point fixation is usually adequate for
the non-comminuted pediatric zygomatic
complex fracture.
145
Mandibles are 50 percent of ped facial fx, What is treatment for infants under 1 year of age, how about for displaced fractures in children, how about for significantly displaced or comminuted.
Infants less than 1 year of age should be
–
observed. Diet modification is not required.
– For mandible fractures in young children
–
that are not displaced and occlusion is sta-
ble, conservative management, close obser-
vation, and soft/liquid diet is appropriate
treatment.
– Displaced fractures need to be stabilized
–
and immobilized.
– Open reduction and internal fixation
–
(ORIF) should be used only for fractures
significantly displaced or comminuted.
Techniques for stabilization and immobiliza-
tion in pediatric patients include maxilloman-
dibular fixation, fabrication of a lingual or
occlusal splint, open reduction internal fixa-
tion, or a combination of these techniques.
146
How long to IMF someone under 12? what if it involves the condylar process.
If maxillomandibular fixation (IMF) is used,
closure for 2–3 weeks is adequate for children
less than 12 years of age. Less time, 1–2 weeks,
is appropriate, if the fracture involves the con-
dylar process.
147
when to use circumandibular wires, what about risden cables?
n a patient without adequate dentition to secure
arch bar placement skeletal fixation with wires
at the circum-mandibular, circum- piriform, cir-
cum-orbital, and circum- zygomatic regions can
be used to attain maxillomandibular fixation.
Acrylic splints can be fabricated to provide
stability to the mandible. They can be used
when no deciduous or permanent teeth are
present or fabricated on the occlusal or lingual
aspects of those teeth that are present. They
require taking impressions, pouring diagnos-
tic models, cutting the models at the regions of
fracture and restoring the segments to proper
occlusion with wax. An acrylic splint is then
fabricated off of these models and secured to
the patient’s mandible with wires (either cir-
cumdentally or circum-mandibular).
A Risdon cable can also be used as a substitute
to bulky arch bars that will not conform to the
small deciduous teeth. The technique which
entails twisting a long 24-gauge wire together
and is secured to the posterior molars with addi-
tional 24-gauge wires was described by Ri
148
when to remove titanium plates and screws for pads patients
Titanium plates and screws may be used although
may require a secondary surgery for removal in
patients 2–3 months after the initial placement.
This is secondary to concerns regarding migra-
tion of the titanium plates and inhibition or alter-
149
children less than age 6 are more likely to
have intracapsular fractures and those older
than 6 years of age are more likely to have
condylar neck or extracapsular fractures
150
How long to immobilize IMF a condylear fracture
If the fracture is immobilized in IMF,
7–14 days is generally adequat
151
What are biodegradable plates made of and what is the complications, what are the available ones
Complex bending of the plates requires a heat
source to allow the polymer chains to bend
and not fracture. This may present a problem
when fixating regions that require more com-
plex shaping.
Higher rate of visible or palpable hardware
postoperatively due to greater thickness than
metal.
Foreign body reaction or sterile abscess may
occur during the biodegradation and absorp-
tion process.
Polyglycolic acid (PGA) and pure poly-L-lactic
acid (PLLA) have caused adverse reac-
tions during degradation.
Unable to be re-sterilized.
Limited shelf life.
Inion CPS® system, Tampere, Finland.
Zimmer-Biomet Lactosorb® (Lorenz Plating
System).
DePuy Synthes Rapidsorb® Rapid Resorbable
Fixation System
152
treatment for intrusion, extrusion, displacement, avulsion
Intrusion.
– Orthodontic assisted eruption is favored:
–
must be done slowly over 3-4 weeks and
once in position must be stabilized for 2-3
months.
– Endodontic treatment is based on follow-
–
up findings.
– If a deciduous tooth is intruded, it may be
–
extracted if it is impeding eruption of per-
manent tooth.
*
Extrusion.
– Usually can be repositioned and splinted
–
for 1–3 weeks.
– Endodontic treatment is usually needed,
–
and patient should be evaluated at
follow-ups.
*
Displacement
– Reposition tooth and alveolus and splint.
–
– Repair any gingival lacerations.
–
– Follow up to determine the state of pulp
–
and periodontal damage to determine fur-
ther treatment.
*
Avulsion.
– Rinse t Rinse tooth immediately with patient’s
–
saliva or saline and replant immediately.
– Try to limit contact with root surface.
–
– If patient cannot replace tooth, then it
–
should be placed in storage medium
(HANKS Balanced Salt Solution or milk).
Do not scrape walls of socket or root sur-
face, as this will destroy viable periodontal
tissue.
– Semi rigid splint for 7–10 days.
–
– Strict follow up to evaluate for root resorp-
–
tion and ankylosis as well as need for end-
odontic treatment.
Alveolar Fractures.
– Place segment into proper position.
–
– Stabilize for 4 weeks using arch bars or
–
acrylic/composite splint.
– Teeth in segment may need endodontic
–
treatment.
153
What is DA stabilization periods
Alveolar Fractures.
– Place segment into proper position.
–
– Stabilize for 4 weeks using arch bars or
–
acrylic/composite splint.
– Teeth in segment may need endodontic
–
treatment.
154
